Resident Eye Care Associates - Order Eye Care Supplies
Name
*
First Name
Last Name
Supplies to Order:
*
HypoChlor $20
Retaine $15
Retaine PM $15
Heat Compress $20
Cool Compress $20
Stye Compess $20
Restore Vitamins 1 pk $32
Restore Vitamins 3 pk $90
Restore Vitamins 6 pk $174
Zeaxanthin Vitamins 1 pk $35
Zeaxanthin Vitamins 3 pk $99
Zoria Boost $110
Zoria Boost Mascara $50
Zoria Combo Package(Boost&Boost Mascara) $150
Quantity
How would you like to receive the item?
Recieve a call to pick it up
Have the item shipped for $3.95
Credit Card Number
*
Expire Date
*
CCV Code
*
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Notes to the doctor
Submit
Should be Empty: